Attitude and Awareness of Medicinal Plants in Treatment of Kidney Lithiasis in Eastern Morocco: a Retrospective Study

International journal edited by the Institute of Natural Fibres and Medicinal Plants National Research Institute Vol. 67 No. 2 2021

Received: 2020-11-22 DOI: 10.2478/hepo-2021-0011 Accepted: 2021-05-07 Available online: 2021-06-10

EXPERIMENTAL PAPER

Attitude and awareness of medicinal plants in treatment of kidney lithiasis in eastern Morocco: a retrospective study

BOUCHRA EL GUERROUJ1 , NOUREDDINE BENCHEIKH2 , MOHAMED BOUHRIM2 , LOUBNA KHARCHOUFA2 , HAYAT OUASSOU2 , HAMADA IMTARA3

1Laboratory of Water Environment and Sustainable Development Faculty of Sciences Mohammed First University Oujda, Morocco

2Laboratory of Bioresources, Biotechnology, Ethnopharmacology and Health URAC-40, Department of Biology Faculty of Sciences Mohammed First University Oujda, Morocco

3Faculty of Arts and Sciences Arab American University Palestine P.O. box 240 Jenin, Palestine

*corresponding author: phone: +972 592 030 458; e-mail: [email protected]

Summary

Introduction: Kidney stone is a major public health problem. Over 5% of the population is affected by kidney stones, with causes a lifetime risk of transmitting renal lithiasis of about 8 to 10%. Objective: The goal of our study is the attitude and awareness of lithiasis patients regarding the use of medicinal plants in eastern Morocco. Methods: We carried out a study on lithiasis patients to retrospectively identify medicinal plants used in this disease, using a pre-established questionnaire. The study was carried out from 10 December 2017 to 28 February 2018. Results: Our survey describes several medicinal plants used to treat renal lithiasis in eastern Morocco. Most patients used Herniaria hirsuta L., Zea mays L., Urtica dioica L., and Petroselinum crispum (Mill.) Fuss. This preliminary study showed that the first reason to use medicinal plants in half of lithiasis patients is to calm the pain and expel the stones. The primary source of plant use information is oral tradition. However 67% of lithiasis patients are unaware of the harmful and toxic effects that can appear.

Herba Pol 2021; 67(2): 17-28 18 B. El Guerrouj, N. Bencheikh, M. Bouhrim, L. Kharchoufa, H. Ouassou, H. Imtara

Conclusion: Medicinal plants must, like medicines, comply with strict requirements and standard rules of use to which only the specialist in herbal medicine can respond and sensitize people to the dangers of ir- rational consumption of medicinal plants.

Key words: renal lithiasis, medicinal plants, eastern Morocco, retrospective study

Słowa kluczowe: kamica nerkowa, rośliny lecznicze, wschodnie Maroko, badanie retrospektywne

INTRODUCTION believe that natural is the synonym of harmless [10]. In Eastern Morocco, studies on renal lithiasis are few Urinary lithiasis or stone disease is a pathology that and focused on the determination of the epidemiol- presents a major public health problem. It affects 10% ogy and chemical composition of the complex prepa- of the population in industrialized countries [1]. It is rations [11, 12]. However, no studies have been car- characterized by the formation of crystalline concre- ried out regarding the place of medicinal plants in the tions developing in a basin and/or calyxes of kidney treatment of renal lithiasis. To contribute to the study and causing partial or total obstruction to the normal of the place of medicinal plants in the treatment of urine flow [2]. Several factors can be linked to the renal lithiasis in eastern Morocco, we focused on the formation of these calculi such as sex, ethnic group, attitude and awareness of patients regarding the use of food intake, genetics, climatic aspects, and metabolic plants to expel kidney stones. disturbances [3]. In 50% of cases, it is a recurrent disease. Some forms are particularly severe and can lead to kidney failure. Urinary lithiasis is the third cause MATERIAL AND METHODS of chronic kidney disease at 9.8% [4]. The annual prevalence of urinary lithiasis in Western countries Study sample has nearly tripled in the last 50 years. These phenom- ena are explained by the rise in the socio-economic The target population consisted of 184 patients suf- level and the change in eating habits, such as the con- fering from urinary stone disease in different cities sumption of salt, which was multiplied by 3, and that of eastern Morocco. Participants interviewed were of protein multiplied by 5 [5]. Besides, the chemical informed about the objectives of the study. All pa- nature of the calculus has changed. The end of the 19th tients were informed that their personal data would century was characterized by the dominance of calcu- be analyzed as a part of this survey and consented lations based on purine, whereas in recent years have for their data to be included in the analysis. experienced an increase in the frequency of Oxalo- calcium in three-quarters of cases. Since Morocco’s eating habits change from one generation to another, Epidemiological survey the epidemiological profile of the calculations of Mo- roccan patients is similar to that of the industrialized In order to highlight the attitude and awareness of countries [6]. With the increase in the number of pa- lithiasis patients towards the use of medicinal plants in tients and the painful nature of the disease, some pa- eastern Morocco, a study was conducted on patients tients choose the use of traditional medicines, which is with renal lithiasis to retrospectively identify the me- mainly based on the use of plants, to meet their health dicinal plants used, using pre-established question- care needs, which is a very old practice implemented naire (fig. 1). This study was carried out through sev- by almost 80% of the population worldwide [7]. For eral continuous visits over a period from 10 Decem- centuries, our ancestors appreciated the virtues of ber 2017 to 28 February 2018. The places and health plants. They have transmitted and developed their services visited in this study are the hospital urology knowledge and experiences in the use of medicinal and nephrology services in nine provinces of eastern plants to overcome suffering and heal the wounds [8]. Morocco (Oujda, Berkane, Nador, Jerada, Taourirt, Today, plants still play a very important role in medi- Saidia, Figuig, Bouarfa and Bouanane), and the urol- cal traditions worldwide. However, the rules of their ogy and nephrology department of the CHU Mo- use sometimes lack rigor and do not take into account hammed VI of Oujda was also visited regularly (this the new requirements of modern therapeutics [9]. The hospital welcomes patients from different regions of traditional use of medicinal plants is mainly based on Eastern Morocco with serious health problems that the idea that plants are a means of treatment without cannot be treated in the hospitals of their cities). Also harmful effects because they are natural. Consumers private centres were visited (Oriental Nephrology Attitude and awareness of medicinal plants in treatment of kidney lithiasis in eastern Morocco: a retrospective study 19

Figure 1. Pre-established questionnaire

Vol. 67 No. 2 2021 20 B. El Guerrouj, N. Bencheikh, M. Bouhrim, L. Kharchoufa, H. Ouassou, H. Imtara and Hemodialysis Center and Al Hakim Alaoui He- Statistical analysis modialysis Centre in Oujda). All patients included in this study were interviewed using a pre-established All data collected from respondents were copied questionnaire and structured into three main axes as and analysed by Microsoft Excel 2016. follows: 1) gathered different identifying characteris- Ethical approval: The conducted research is not re- tics of the patients (sex, age, living environment, level lated to either human or animal use. of education), 2) specifies a patient history, which is a medical monitoring and its effectiveness, 3) all the modalities concerning the use of anti-lithiasis plants RESULTS AND DISCUSSION (identification of plants used in the treatment of lithiasis, the method of preparation, timing and frequen- Socio-demographic data cy of intake, different sources of information about these plants, reasons for use, the patient awareness of The socio-demographic characteristics of lithiasis the adverse effects of these plants. patients (places of residence, age, sex, level of education) were summarized in table 1. Identification of medicinal plant species Distribution of lithiasis patients according to All local plant names collected during this study place of residence were transformed into botanical names, based on the work of Jamila and Mostafa [11]. To ascertain In this study, a total of 184 lithiasis patients were in- the scientific names of plants compiled from the terviewed in urology departments (Al Farabi Region- survey, we used a standardized database [12]. al Hospital and Mohamed IV University Hospital). We found that 138 lithiasis patients are from urban areas (75%), and 46 are from rural areas with (25%) Ethical (tab. 1). This difference can be explained by regional variations in population density [13], and the differ- Patients’ data is kept safe and secure, to protect their ence in lifestyle between rural and urban population. confidential information. Each patient detailed information is replaced by a code, and a record was established to identify different patients. This reg- Distribution of lithiasis patients according to age ister was only accessible to the principal investiga- tor. Data collection and data entry was done anony- As shown in table 1, the prevalence of urinary stones mously using this code. varies according to age [15]. People in the age group

Table 1. Socio-demographic characteristics of lithiasis patients

Distribution of patients Categories Number of patients Percentage of patients [%]

Men 79 43 By sex Women 105 57 Urban 138 75 By habitat Rural 46 25 < 30 years 48 26.41 By age range 30–60 104 56.6 > 60 years 32 16.98 Illiterate 42 23 Primary education 20 11 By education level Secondary education 48 26 University education 74 40 Attitude and awareness of medicinal plants in treatment of kidney lithiasis in eastern Morocco: a retrospective study 21 from 30 to 60 arrive first with a percentage of 53%, Patient history followed by people younger than 30 (26.41%), and over 60 are the least affected by lithiasis (16.98%). The medical consultation The highest incidence of lithiasis in the age group 30 to 60 in our study is proven by other works con- The consultation with a qualified doctor is an in- ducted on the territory of Morocco[13, 16–18]. tegral part of the process in treatment, also aims at Also, the increase in the incidence of lithiasis in the patient safety. Besides, the consultation can help in age group 30–60 is confirmed in other studies pub- diagnosing disease and to determine the appropri- lished outside Morocco such as in Turkey, Spain, ate treatment. The patient may expose themselves and United States [19-21]. to risk if they avoid consulting a doctor [22, 23]. In the present work, the results showed that 96% of those interviewed consulted a doctor to treat kidney stones, while 4% did not consult the doctor. Our re- Distribution of lithiasis patients according to sex sult shows that the majority of patients who use medicinal plants have a higher level of awareness and In this epidemiological study, out of a total of education. 184 lithiasis patients, 79 are men (43%) and 105 are women (57%) (tab. 1). The sex ratio was 1.33. Several factors can influence the difference in the incidence Monitoring and effectiveness of treatment among women and men, but the main factor that can be taken into account is the difference in sex The most common methods used to treat kidney hormones [13]. stones are ESWL lithotripsy and medication therapy [24]. In the present work, among 96% of the patients who consulted the doctor, 92% followed their medi- Distribution of lithiasis patients according to cations treatment, while 8% of people did not follow educational level the treatment (fig. 2a). On the other hand, among patients who followed their treatment, 53% confirmed that the medications treatment was effective, while Regarding educational level (tab. 1), the results 47 confirmed the ineffectiveness of the medications showed that a large proportion of lithiasis patients in the treatment (fig. 2b). Studies have shown that have a university education level (40%), followed by there is no satisfactory medication to use in clini- patients with a secondary level (26%), and illiterates cal treatment despite significant progress in study- (14%). Finally, the least affected by lithiasis are those ing the biological and physical aspects of kidney with a primary level (11%). stones. Also, despite the great development in the

Figure 2. Distribution of lithiasis patients by treatment follow-up (a) and by treatment effectiveness (b)

Vol. 67 No. 2 2021 22 B. El Guerrouj, N. Bencheikh, M. Bouhrim, L. Kharchoufa, H. Ouassou, H. Imtara techniques used to break up the kidney stones, data indicate that exposure to shock waves in therapeutic doses may cause acute kidney injury, a decrease in kidney function, and an increase in the frequency of the stone. Besides, residual stone fragments remain- ing and the possibility of infection after ESWL are a serious problem in treating stones [24-26]. On the other hand, many studies in vitro, in vivo and clinical trials have proven that phytotherapeutic agents can be useful either as an alternative therapy or as an aid in managing urolithiasis [24, 27-29]. Figure 3. Frequency of use of medicinal plants with syn- Phytotherapy thetic drug treatment

Use of medicinal plants in the treatment of lithiasis diseases Among the strategies used in preventing and treating kidney stones is the use of medicinal plants In the present survey, 184 patients with renal calculi (Herbs). In the present work, the results of the survey were questioned, of which 92% from them use me- indicated that many lithiasis patients use various spe- dicinal plants to treat kidney stones, while patients cies of plants for treatment, as shown in the figure 4. who did not use herbal remedies had the lowest The species with the highest frequency of mentions in rate (8%). In fact, many studies have reported that the interview were Petroselinum crispum (Mill.) Fuss., the percentage of the uses of medicinal plants oscil- (28%), Herniaria hirsuta L. (25%), Zea mays L. (12%), lated between 55 and 95%, according to the region Urtica dioica L. (6%), and others (29%). where the survey was undertaken. The rate of use of the medicinal plants’ changes according to area, ethnology, the richness of the sector in medicinal plants and home environment [31-34]. Through- out history, medicinal plants have been used in the treatment of many diseases due to their lack of side Petroselinum crispum (Mill.) Fuss effects [35-36.] Moreover, natural products have Urtica dioica L. played a significant role throughout the world in Herniaria hirsuta L. Zea mays L. treating and preventing human illness. However, Others herbal medicines are regarded as an acceptable, cheap, easily available, and safe source of active constituents for pharmaceutical industry [36]. In Morocco, even today, plant medicines are freely available to the public without a prescription. As Figure 4. shown in figure 3, among 184 patients with lithi- Frequency of use of medicinal plants by lithiasis asis, 30.61% from them use medicinal plants before synthetic drugs, 36.73% from them use medicinal patients plants after synthetic drugs and 32.65% from them use herbals in parallel with synthetic drugs. These • Petroselinum crispum (Mill.) Fuss. Parsley is an results are attributed to several factors, including herb belonging to the Apiaceae family. This plant 1) erroneous belief that herbal products are supe- is distributed mainly in the Mediterranean re- rior to synthetic drugs, 2) patients’ belief that their gions, western Asia and several European coun- physicians have not properly identified the prob- tries [37, 38]. As a complementary/alternative lem, hence the feeling that herbal remedies are an- treatment, parsley and its extracts were used to other option, 3) and dissatisfaction with the results treat various renal diseases [39-41]. The anti-uro- from orthodox pharmaceuticals and the belief that lithiasis of P. crispum was demonstrated in rat, as herbal medicines might be effective in the treat- the results showed the ability of parsley extracts ment of kidney stones. to prevent precipitation of calcium oxalate, urine Attitude and awareness of medicinal plants in treatment of kidney lithiasis in eastern Morocco: a retrospective study 23

supersaturation, and urinary protein excretion. from person to person with a percentage of 25%. Moreover, parsley extract regulates pH of urine at Herbalists represent 14%, and the media 6% (fig. 6). a value at which calcium oxalate crystals could be maintained as dispersed particles, and the elimi- nation of these crystals could be facilitated [42]. • Herniaria hirsuta L. is a flowering plant belonging to the family of Caryophyllaceae. In traditional folk medicine, lithotriptic and anti-lithogenic properties have been attributed to Herniaria species [43]. H. hirsuta is a Mediterranean traditional medicinal plant widely used in Morocco to treat lithiasis patients [44, 45]. Its aqueous extract exerted a significant preventive effect against the formation of calcium oxalate kidney stones [43, 45]. Also, studies have proven the effectiveness ofH. hirsuta plant in Figure 5. treating kidney disease, in addition to its effective role in prevention against the formation of urinary The reason for the use of medicinal plants by stones via inhibiting the deposition and growth of lithiasis patients calcium oxalate crystals [28, 46]. • Zea mays L. is a flowering plant (variously called maize or corn) belonging to the Poaceae family. It is a medicinal plant used in the treatment of urinary tract and kidney stones [47]. It was the herbal medicine cited most often as a diuretic and antilithiasic [48, 49]. • Urtica dioica L. (stinging nettle) is a perennial plant belonging to the family of Urticaceae [50, 51]. The activity of this plant in treating urinary tract problems and kidney stones has been proven throughout history. Various extracts of U. dioi- Figure 6. ca, including methanolic extract, decreased urine The sources of information regarding the use of creatinine level, and reduction of supersaturation medicinal plants of lithogenic enhancing agents [50]. • Other medicinal plants: Citrus limon (L.) Os- beck, Malus domestica Borkh, Zizyphus lotus L. The mode of preparation (Desf.), Origanum compactum Benth., Ocimum basilicum L., Verbena officinalis L., Allium cepa The mode of preparation of these herbal medicines L., Cuminum cyminum L., Syzygium aromaticum was grouped into three categories (fig. 7). The most (L.) Merr. & L. M. Perry, Cucurbita pepo L., Li- commonly used methods of preparation were decoc- num usitatissimum L., and Allium sativum L. are tion (64%) followed by infusion (26%), and powder also used in the treatment of kidney stones. (10%). The preparation of decoction for the treat- In line with this, the utilization of abovemen- ment of kidney stones is a common practice among tioned medicinal plants for self-medication by pa- communities in Morocco [52] and other parts of the tients with urinary stones varies from one to anoth- World [47]. Decoctions can often be found as one of er. In our study, it was found that 65.50% of patients major forms of drug preparation in ethnobotanical used them to expel kidney stones, 25% to potentiate practice as it is easy to prepare by boiling the plant the action of synthetic drugs, 11.80% used them be- parts in water until the volume of the water reduced cause they were influenced by their culture of used to a minimum or required amount [53]. On the other herbal remedies to treat kidney stones and 8.60% of hand, the use of the decoction shows that the popula- them used herbs for their low cost (fig. 5). tion has confidence in this type of preparation and On the other hand, most of our lithiasis patients finds it suitable for warming the body and disinfect- select these herbal medicines based on anecdotal ing the plant, also the decoction makes it possible to information from other patients who experienced collect the most active ingredients attenuates or can- a kidney stone before (55%), followed by viva voce cels the toxic effect of certain recipes [54].

Vol. 67 No. 2 2021 24 B. El Guerrouj, N. Bencheikh, M. Bouhrim, L. Kharchoufa, H. Ouassou, H. Imtara

study revealing the predominance of a handful of weight used in the preparation of different herbal remedies[55, 56]. Most users of herbal medicines do not respect the doses and do not consider that high doses can be toxic and even fatal. Nearly 500 years ago, Swiss physician and chemist Paracelsus ex- pressed the basic principle of toxicology: “All things are poison and nothing is without poison; only the dose makes a thing, not a poison”. This is often con- densed to: “The dose makes the poison.” It means Figure 7. that a substance that contains toxic properties can Method of preparation of herbal medicines by the cause harm only if it occurs in a high enough con- studied patients centration [57].

Frequency and duration of use Dose determination According to each patient, medicinal plants are Over a half of patients (51%) weighed their phytod- applied one to several times a day to treat kidney rugs with hand when preparing, then come spoon stones. In this study, only 7% of the remedies were (28%) and 21% of patients does not use a precise taken one time a day, 52% two times a day, 19% dose. Petroselinum crispum and Herniaria hirsuta three times a day, and 25% several times a day (fig. are often used by the handful while Urtica dioica 8a). The duration of the treatment with the plants and Zea mays are used in imprecise doses by the varied considerably, according to the patients ques- majority of patients, as other plants pointed in ta- tioned ranging from few days to several years. In- ble 2. These reports are in coherence with previous deed, 6% of lithiasis patients used the plants from

Table 2. The doses used for each plant

Petroselinum Urtica dioica Herniaria hirsuta Zea mays Others Plant dose crispum [%] [%] [%] [%] [%] Pinch 0 20 5 10 0 Spoon 18.18 20 30 40 13.04 Handle 45.45 20.00 35.00 0 39.13 Not precise 36.36 40.00 30.00 50.00 47.82

Figure 8. Frequency (a) and duration (b) of the use of medicinal plants in the treatment of kidney stones Attitude and awareness of medicinal plants in treatment of kidney lithiasis in eastern Morocco: a retrospective study 25 one week only, 24% from 2 weeks, 16% from one Conflict of interest: Authors declare no conflict of month, and 54% until healing (fig. 8b). The dura- interest. tion of the treatment sometimes may be extended for a long period depending on the severity of the disease, age of the patient, and the diet they used to REFERENCES take from childhood onwards [58]. 1. Daudon M, Traxer O, Lechevallier E, Saussine C. Épidémiologie des lithiases urinaires. Pro- Plants toxicity grès en Urol 2008; 18:802–14. doi: https://dx.doi. org/10.1016/j.purol.2008.09.029

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